Anorexia and Trait Theory

Anorexia nervosa and trait anxiety

Anorexia Nervosa and Trait Anxiety

Behavioral theorists ponder behavior change and persistence after therapy is completed. This paper queries whether physically hard-wired behavioral responses can truly be changed. Through investigation of the Big Five personality domains as they correlate with development of anorexia nervosa (AN), and contextual neurophysiological findings, treatment options for adolescents and adults are enhanced.

Anorexia as behavior disorder

Anorexia nervosa (AN) involves excessive weight loss or failure to attain expected weight through extreme food restriction, fear of gaining weight and failure to recognize the low weight and the consequences (Meier, Bulik, Thornton, Mattheisen, Mortensen & Petersen, 2015). It is also hypothesized to be a “disorder characterized by altered cognitive control processes underpinned by dysconnectivity within the FPN” (Boehm, Geisler, Friederike, King & Ritschel, et al., 2015, p. 384), the frontal-parietal network--which underlies many mental disorders. These alterations are consistent with a “heightened cognitive control” mechanism (Boehm, et al., 2015). Many AN studies have concentrated on pathological characteristics such as psychoticism, perfectionism and impulsivity (Dubovi, Li & Martin, 2016).

Research has shown that mental disorders fall into relationship with personality trait dimensions. “Negative emotionality (a trait similar to neuroticism) has been linked to internalizing (Uliaszek & Zinbarg, 2016, p. 159). A liability-spectrum approach has been taken by many researchers who find a few liability factors underlie several mental disorders. Two of these factors are depression and anxiety disorders, which are associated with internalizing factor and highly correlated with eating disorder (ED), generalized anxiety disorder (GAD), panic disorder and obsessive-compulsive disorder (OCD). In effect, EDs are negatively correlated with competence, self-determination, assertiveness, values and actions—and are positively associated with neuroticism. While a three-factor model has been confirmed in many studies containing internalizing/externalizing and thought disorder—a fourth factor of pathological introversion has also come to be recognized (Uliaszek & Zinbarg, 2016).

Constructs related to EDs include depression, self-esteem and neuroticism (Levinson & Byrne, 2014), with AN specifically correlated with anxiety—“upper estimates suggesting that 83% of patients with anorexia nervosa display a case history of one or more anxiety disorders” (Meier, et al., 2015, p. 524).

Farstad, McGeown & vonRanson (2016) suggest that personality traits affect ED expression and treatment. Avoidant and obsessive personality factors are most prevalent in both AN and BED (binge eating disorder). All ED profiles are characterized by neuroticism, perfectionism, avoidance, lower extraversion and self-direction, but purging is highly correlated with borderline and paranoid personality profiles. A comprehensive cognitive-behavioral model of anxiety suggests that to fully address the anxiety disorder an individual must modify their feelings (anxiety), beliefs or thoughts (core fears), and behaviors (avoidance)” (Levinson & Byrnes, 2014, p. 271). Levallius, Roberts, Clinton & Norring (2016) conclude that “personality significantly predicted both recovery (70% of patients) and symptom improvement” (p. 447). The gain most predictive of recovery from EDs is in the trait of assertiveness where the Five-factor model is used to predict treatment outcome.

Levinson & Byrne (2015) devised a Fear of Food Measure (FOFM) for the trait fear of food which includes anxiety about eating, food avoidance behavior, and fear concerns (after eating). They further hypothesized that a fear of food may be a factor in all ED. All participants in the study had high comorbidity for anxiety or depression. “Both anxiety about eating and feared concerns were able to predict disordered eating over and above restraint, emotional eating, trait anxiety and negative effect” (p. 278).

A large Canadian study confirmed the correlation between depression and addictions with anorexia and bulimia. Non-cognitive factors--personality traits of motivation, optimism and positive affect, impulsivity and assertiveness, were measured using the French version of the Trait Meta-Mood Scale (TMMS). A three-factor structure of emotional intelligence characteristics—attention, clarity, repair—measure a propensity toward attention to emotions, and difficulties with imagination in women with EDs. Difficulty in emotional regulation was associated with repair—in particular, women with AN had difficulty identifying emotions. Inferior intelligence quotient scores in those with AN were due to problems with introspection and emotion regulation (Maria, Boudier, Duclos, Ringuenet & Berthoz, 2016).

Current Findings in Trait Theory

Current neurobiological research and the Five Factor Theory

Levinson & Byrne (2015) assessed trait anxiety and fear around eating and food using a short measure of the Big Five factors: openness, conscientiousness, extraversion, agreeableness, and neuroticism. In context with ED, self-esteem and depression scales, feared concerns were the only predictor of an ED—removing this factor, anxiety about eating became the prominent predictor of ED. In factor-analysis with the State Trait Anxiety Measure (STAI-A) found fear of food moderately correlated with depression, negative affect and trait anxiety. Common comorbid diagnoses were those of GAD and SAD (social anxiety disorder). It is possible that feared concerns are increased by anxiety to disordered eating, with food restriction and avoidance behaviors, reinforcing a negative feedback loop (Levinson & Byrne, 2015).

Uliaszek & Zinbarg (2016) found that internalizing factor in ED is negatively associated with the Big Five factor of openness, which suggests a lack of flexibility in cognition and behavior. Neuroticism is also associated with being overweight and the perception of being overweight in those with AN as well; extraversion has been correlated with misperception of being taller and thinner—these associations were similar across ethnic groups (Sutin & Terraciano, 2016). In college-aged men, bulimia was highly associated with neuroticism; purging was correlated with openness. Overall, AN associated with mental stability but not neuroticism in young men—the authors stating apparent calmness or lack of expression may be hiding inner characteristics (Dubovi, Li & Martin, 2016).

In matching personality with psychiatric disorders, Lo, Hinds, Tung, Franz, Fan, et al., (2017) used genetic markets to correlate extraversion with ADHD (attention deficit-hyperactivity disorder), and openness with schizophrenia and bipolar disorders. Intraversion was associated with internalizing disorders such as depression and anxiety and may thus be associated with EDs.

Genetics, brain research, endogenous and developmental factors

Clinical models of AN suggest that perception and coping with emotional content contributes to symptoms expression. "In particular, the self-report of restrictive behaviors, body checking, purging, and binge eating appears to be related to daily anxiety and trait disturbances in affect liability" (Hildebrandt, Grotzinger & Schultz, 2016, p. 69). A decreased neuronal response, in areas of attention and processing, may create sensitivity to looks of disgust. High levels of perceived disgust are correlated with increased amygdala activity, and "patients manage the feeling of disgust specifically via food avoidance" (Hilderbrandt et al.,2015, p. 70). Enhanced saliency of emotional stimuli is associated with elevated testosterone levels. Especially among adolescent girls, testosterone levels relate to the activation of threat level in limbic regions of the brain—although most have less hormonal production than normal controls. The highest symptomatic days are linked to high saliency of negative affect (Hildebrandt, Grotzinger & Schultz, 2016).

Other studies find difficulties in brain monitoring, metacognition and theory of mind (identifying with others' emotional states), even where starvation effect, depression and anxiety are absent in a Japanese study. Difficulty with changing tasks, social cognition and verbal memory may be due to underlying anxiety and depression, but previous studies have connected these with traits of ASD (autism spectrum disorders)—many with ASD also have EDs (Hamatani, Tomotake, Takeda, Kameoka, Kawabata, et al., 2016).

Rigidity in cognition is a trademark of AN, OCD and ASD. A maladaptive rule adherence creates a self-imposed need to rigidly adhere to even arbitrary rules (Gross & DeDreu, 2017). In Milgram's (1963) obedience-to-authority experiments, many participants obeyed the unreasonable rules that they should administer painful electric shocks to experimental subjects. While adhering to rules helps one to belong to their society, blindly following rules can affect one's ability to adapt, problem solve and act on new opportunities (Gross & DeDreu, 2017). Adults who have a high need for conformity and sameness, when treated with oxytocin, relaxed their self-imposed criteria, perhaps allowing trade-off of perceived external rules, for internal desires (Gross & DeDreu, 2017). Although adolescents with AN already show rigid thinking, perfectionism and OCD traits, vanNoort, Kraus, Pfeiffer, Lehmkuhl and Kappel (2015) suggest that problems with cognitive flexibility may develop over time and result in cognitive weaknesses in adults.

Brain imaging shows grey matter atrophy in the lateral-frontal brain of AN patients, with a reversal in recovery. Despite normalized brain functions, some still show hyperactivation in some of those circuits. These distortions in resting-state function connectivity in recovered patients may be showing a trait marker for the disorder (Boehm, et al., 2015).

In twin studies, as well as family genetics, AN has been significantly associated with panic disorder. Research has shown alterations of serotonin metabolism in the amygdala and other middle brain areas which regulate emotion and fear. While "parental anxiety disorders in aggregate were not associated with an increased risk of anorexia nervosa in offspring…paternal panic disorder significantly increased the offspring's risk" (Meier, et al., 2015, p. 526). OCD was associated with an even higher risk of genetic transmission—especially in males. Shared personality traits of perfectionism, rigidity and harm avoidance were seen in families with anxiety and AN (Meier, et al., 2015).

The need for structure and predictability in many psychopathologies has been hypothesized as an oxytocin deficit. With oxytocin gastro-nasally introduced, self-imposed rules were relaxed in those who had a heightened need for structure. "Oxytocin up-regulates creative thinking and reduces convergent processing" (Gross & DeDreu, 2017, p. 432)—but can have negative consequences in those with borderline personality disorder, activating more paranoia possibly through the shared dopaminergic pathway (Gross & DeDreu, 2017).

In studies of transgender persons with ED, male-to-females developed weight phobia and AN to appear more feminine; female-to-males tried to reduce curves and look more masculine. Studies show that most transgender individuals have improved eating following sex re-assignment surgery. Those who resume ED symptoms may be portraying trait anxiety as it relates to AN (Strandjord, Ng & Rome, 2015).

Multimodal treatment of anorexia nervosa

In a meta-analysis conducted by Roberts, Luo, Briley, Chow, Su & Hill (2017), domains of emotional stability and extraversion were the most profoundly changed through interventions—the type of therapy employed did not matter. Patients with anxiety disorders changed the most—even in non-clinical interventions—with long-reaching effecst after the end of therapy (Roberts, et al., 2017).

EEG activity is increased in brain areas associated with food craving. Using alpha/theta (A/T) neurofeedback training, subjects show a reduction of physiological food cravings along with planned food consumption. The subjects learn to slow their brain activity, affecting the insula, para-hippocampal and temporal gyrus—all areas which cue food reactivity. Ten sessions of A/T training can reduce food consumption, and persist for at least four months (Imperatori, Valenti, Della Marca, Amoroso, Massullo, et al., 2016).

Adolescents in a CRT (cognitive remediation therapy) program participated in cognitive strengthening exercises to work on flexibility and attention to detail. In adults with AN there is an inability to switch tasks, adapt to environmental situations and inability to process globally—rather, they focus narrowly on minor details. CRT was combined with CBT or individual therapy for outpatients, and nutrition therapy and dialectical behavior groups for inpatients. Just as in other recent trials with adolescents, several neuropsychological domains were improved, including detail processing, and ability to shift attention and change tasks—the AN group improved in cognitive flexibility, while the control group showed no significant change after CRT. Pre and post-intervention showed a very large effect size improvement for the AN group on the STAI(C) (trait inventory for children), the DIKJ (depression inventory for children and adolescents) and ABOS (Anorectic Behavior observation scales). In the tasks, flexible decision-making became more accurate and faster in those with AN, but on self-evaluation about 10% judged themselves as less efficient; control subjects rated their abilities consistent with their results. The exercises did not reach the hypothesized increase in central coherence (the ability to focus broadly)—but then, one has to narrowly focus in order to perform the tasks being tested. It was also hypothesized that improvement may come over time, as adults showed more flexibility in thinking six months after the intervention. CRT improved the quality of life over the long term in adults who previously showed weak cognitive flexibility (vanNoort, et al., 2015).

Family-based treatment (FBT) is the best-evidence treatment for adolescents with AN—with limited evidence for interpersonal therapy or CBT (vanNoort, et al., 2015). Recent trials have shown however, that 60% of AN adolescents remain in clinical low weight categories after treatment. Because adolescence is a critical time in brain development, it is suggested that cognitive flexibility interventions be combined with FBT to help mitigate development of perfectionism and obsession. Cognitive flexibility is measured as ability to perceive control in difficult situations; ability to perceive alternate solutions in difficult circumstances; to generate different solutions during difficult circumstances. Combining FBT with CBT modules and measures for flexibility, Hurst & Zimmer-Gembeck (2015) found "the participants with the longest illness duration demonstrated the largest reduction in the domain of SOP" (p. 940)—a self-oriented perfectionism.

Cognitive Behavioral therapy (CBT) interventions have not been helpful where the insight of the patient is limited and they cannot define antecedents to their behaviors. Until recently, interventions have been based on restructuring maladaptive thought patterns which leads to better responses (Field, Beeson & Jones, 2015). Then began a renaissance of brain research which renewed support for the James-Lange theory that emotions come before thought. Neuroscience-informed CBT introduces interventions which take the processing of threat into account. A shift in brain functioning occurs due to actual or perceived threat, in which the parasympathetic nervous system may freeze rather than fight (Field, Beeson & Jones, 2015). The freeze draws all life resources in toward center, slowing all functions, reducing digestion in preparation for survival.

Engaging the thinking brain can counter freeze states. In the Waves model of CBT, a client is informed of their Wave 1 processing where the body determines the mindset, and notice the activating event, which cascades through hormones to the nervous system, causing anxiety or freeze responses. In Wave 2, activation of the system leads to corresponding secondary emotions such as shame or self-reproach. The intervention attends to physiological reactions and building the brain through higher thinking. Interventions which keep the client in the here-and-now, systematic desensitization, and biofeedback help a person connect mind with nervous system (Field, Beeson & Jones, 2015). Exposure therapy is also a promising treatment for EDs. An in vivo study showed those with higher anxiety ate fewer grams of food. Through exposure to food over time, FOFM (Fear of Food Measure) subscales regarding anxiety about eating, food anxiety behavior and feared concerns after eating were lessened (Levinson & Byrne, 2015).

It is hypothesized that fear of negative evaluation by others is at the core of AN; high levels of trait anxiety about eating is a predictor of ED (Levinson & Byrne, 2015). Walking through the fear with the client, while coaching to anticipate and accept physiological arousal, may be the best way to balance activity between the thinking and emotional brain system (Field, Beeson & Jones, 2015).

The Big Five personality theory provides descriptors of groups of behaviors which are core traits; core traits are enhanced are enhanced through behaviors in a feedback loop. As behaviors in AN, such as under-eating and over-exercising are reinforced, the mind becomes rigid in its responses. New behaviors enacted by the higher executive brain can also be reinforced—this is up to the individual to BE the executive, and direct their brain function. In this way, behavior change becomes biochemical. AN is an outward behavior representing inner imbalances which can be healed; enacting all parts of the brain leads to greater flexibility and balance in life.

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